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Approaching Clinical Decision Making in Nursing Practice with Interactive Multimedia and Case-Based Reasoning
Som Naidu, ( The University of Melbourne
Mary Oliver, ( The University of Southern Queensland
Andy Koronios, ( The University of Southern Queensland

This paper describes the conceptual design, development and formative evaluation of a self-paced multimedia learning resource that is intended to facilitate clinical decision making in nursing practice with case-based reasoning. With the help of a contrived situation, the resource attempts to simulate the complexities of life in a typical hospital ward, which places graduating nurses in the role of problem-solvers. Problem solving in the simulation is based on a rich repertoire of cases and stories that have been extracted from the experiences of expert practitioners. This case-based reasoning architecture reflects a model of learning where graduating nurses are coached in the development of decision-making skills within the context of a contrived but an authentic problem. Formative evaluation of this multimedia resource using structured and open-ended question types has been carried out with individual and small groups of practicing nurses. Their general impressions of this resource, and especially its approach to learning, have been positive. More extensive evaluation of the resource is currently in progress.

1. Educational Problem
In much of Australia (and very likely elsewhere), approaches to the preparation of nursing students for a successful transition into the workplace has been found to be ineffective. Recognizing that more of the same kind of support was not going to be useful, we argued for a radical shift in helping graduating nurses to make the transition into the workplace. Our proposition combines powerful educational technologies and proven learning strategies to build a self-paced technology-enhanced learning environment. Governments, health care organisations and nurse educators have also suggested that in order to prepare better nursing graduates for the challenges of the workplace, there must be alternative ways of preparing graduating nurses for the demands of clinical decision making in situ. An obvious improvement would be increased collaboration between the employing organizations and nursing education institutions to provide realistic learning situations outside the formal classroom, and offered in a self-paced and self-instructional environment. These alternative learning opportunities would need to be solidly grounded in the authentic problems and situations of the nursesí daily routines. The learning tasks would need to be immediately relevant and meaningful to them, and not too removed from their workplace environment.

2. Conceptual Design
As part of this approach, we developed a self-paced multimedia learning environment using the notion of case-based reasoning. Simply put, case-based reasoning is about using cases, which are in the form of stories and experiences of practitioners, to help nurses make decisions about a presenting problem. At the core of the learning environment, a simulation projects many of the complexities of life in a typical hospital ward, making the education of graduate nurses and students case-based and authentic. Learning activities incorporated in this simulation require users to make decisions about the best course of action for resolving critical components of the problem. Users are able to do this after they have listened to the experiences and stories of a wide range of practitioners that are presented in the form of audio/video clips on the CD-ROM. Users can listen to these stories as they please and as often as they like. After they have been through the multimedia environment, they are able to view how experienced nursing practitioners would discuss their actions at a "case conference" where they can reflect on the reasons for their actions and how they might have addressed the situation differently. This learning architecture reflects a situated cognitive model of learning where students and graduating nurses are coached in the development of their strategies for recognizing learning opportunities and critical thinking with the help of authentic cases. The use of this material in situ does not mean throwing out all other resources and abandoning students in a welter of diverse information sources presented in a multimedia learning environment. On the contrary, we suggest leading students very carefully through unstructured problem situations from multiple perspectives, multiple sources of information, and providing careful instructional feedback, not only on content mastery but also on the skills of information-processing, critical thinking, and clinical decision-making.

Our pedagogy is based on the belief that learning is most efficient and effective when it is situated in realistic settings where learners are clear, not only about the reasons for learning but the context or the ecology of their learning environment. This view contrasts with the notion that subject matter can be represented in schemas stored in memory and retrieved when needed. Gestalt psychologists, such as Wertheimer, Kohler, and Koffka, argued in favour of the role of insight, perception and reflection in the learning process as opposed to association based primarily on past experience, such as that proposed by Thorndike, Skinner and Pavlov (Bower and Hilgard, 1981). Because we wanted to create situations that were not only motivating and challenging, but that necessitated learning of facts, principles and procedures, we used a Goal-Based Scenario (Schank, 1997). A Goal-Based Scenario (GBS) is essentially a simulation in which learners assume a main role. Their "goal" is to accomplish the mission or task associated with their main role in the scenario. In order to achieve this goal the learner needs to acquire particular skills and knowledge. This is where the learning is taking place. Goals in this context refer to the successful completion of the task at hand, not the achievement of grades. A GBS serves both, to motivate learners and also give them the opportunity to "learn by doing." As long as a goal is of inherent interest to learners, and the skills needed to accomplish those goals are the targeted learning outcomes, we have a match and a workable GBS. The important idea here is that a GBS is organized around "performance" skills and the result is a student who can perform the specified task.

3. Design Architecture
One of the most harmful misconceptions people have about expertise is that being able and smart comes from knowing a lot of rules. Behind this notion is the sense that reading a lot of textbooks and absorbing what these say will lead one to become an expert. While it does make sense to say that expertise comes from content knowledge, most of that knowledge in practice looks quite a bit different than what you find in textbooks. The architecture of this learning environment follows from the premise that if we are to prepare better graduate nurses for the challenges of the contemporary workplace, we must shift our focus from a content-centred to a case-based reasoning approach. The case-based reasoning approach is based on the principles of a situated cognitive model of learning (Schank, 1997, 1990; Schank and Cleary, 1995). The primary propositions of the situated cognitive model of learning are a) that understanding is gained through our interactions with authentic cases and in situ; and b) cognitive conflict is the stimulus for learning, which also determines the organization and nature of what is learned (Savery and Duffy, 1995). Brown and Palincsar (1989) assert that change is more likely when individuals are required to explain, elaborate or defend their positions to others as well as to themselves, which gives rise to cognitive conflict in an individual. These authors argue that cognitive conflict arises when the learner is exposed to disagreement between existing knowledge and new anomalous information. Chin and Brewer (1993) examined the role of cognitive conflict in promoting conceptual change, and attribute these changes to the following four cognitive attributes: status of the anomalous data in the perception of the students; characteristics of prior knowledge; learnerís perception of the credibility and validity of the new information; and processing strategies. Whether cognitive conflict is experienced by the learner, and if it will result in change is dependent upon those four cognitive aspects ascribed by Chin and Brewer (1993).

In this multimedia learning environment case-based reasoning is used to improve current instructional practices in the education of nurses for their transition into the workplace. (See Figure 1.) The intent of this model is to present students with a contrived but an authentic scenario, which offers them an opportunity to learn in a safe environment, and by making mistakes without injury to real human patients. We argue that mistakes offer real opportunities for learning when these are accompanied by timely and potent feedback. We will now describe this model in some detail.

Clinical Decision Making with Case-Based Reasoning

  • Goal: The "goal" for the learner in this simulation is to deal with the crisis situation and develop an action plan for managing the patient's situation.

Phase I: Case Encounter

  • Learners encounter the case at handover where they are explained its history and pathology.

Phase II: Understanding Problem

Precipitating event

Identifying its causes

Managing the crisis

Learner encounters the precipitating event.

Learner seeks to locate the causes of the precipitating event.

Learner attempts to deal with the crisis and contain it.

Phase II: Seeking Solutions

Making decisions

Listening to Stories

Case-Based Reasoning

Learners are required to make decisions about patient care.

They listen to experts and ask questions about their experiences.

Learners attempt to reason on the basis of the experts' stories.

Phase III: At the Case Conference

Raising issues

Listening to Stories

Developing Care Plan

Learners explore new and related issues to the problem by reviewing sources of information.

They ask experts additional questions about their experiences.

Learners develop their final care plan based on experts' stories.

Phase IV: Developing a Care Plan

  • Learners submit their care plan to the supervisor and receive feedback on their decision making.

Figure 1. Clinical decision making in nursing practice with case-based reasoning. The phases in the model guide users through procedures for using the repository of cases.

3.1 The Goal
As users enter this learning environment a short welcoming video clip explains its context and their "goal" within it. The "goal" for the learner in this simulation is to deal with the crisis situation and develop an action plan for managing the patient's care. This "goal" is not the same as a learning outcome but a means to achieving one or more learning outcomes.
Demo 1. A real G2 streaming movie showing the guide outlining the goal

3.2 Case Encounter
Following statement of the goal, users proceed to the handover. This is a routine event in nursing practice, where nurses coming on for duty are brought up-to-date by their outgoing colleagues on the condition of patients who are in their care. In this simulation this occurs at a small meeting in the presence of the medical practitioner as well as other staff. At this meeting the outgoing nurse outlines the background on one of the patients (Mr. George Parker) around which this simulation is built.
Demo 2. A real G2 streaming movie showing the video clip of handover

3.3 User Actions
After handover, nurses would usually begin their work. At this point in the simulation, a number of options are available to users. They may go to the nurses' station, review their goal, watch the handover video clip, study learning outcomes of the presentation, take notes on the handover, or examine the questions and issues they ought to be considering for preparing their care plan. Throughout the simulation, users can view two versions of each video clip; one displays the entire procedure or event and another is annotated with subtitles to highlight, to the learner, the salient points of a particular procedure or event. If at any time, the user is unsure of what to do, the "now what" facility will offer advice on possible actions. These are a series of short video clips that give general advice on meaningful actions users can take. However, these do not offer specific help to the users, as there is none.

Demo 3. A real G2 streaming sound clip showing an example "Now What" advice

3.4 Taking Notes
This facility enables users to take notes as they work through the simulation. At the moment, this is a simple text editor, which allows for only text input. This is not a very structured facility although it could be made into one, depending on the kind of cognitive support we feel users in this environment need in order to prepare their patient care plan. It could be improved to allow for the accumulation and organisation of other data types such as images, audio and video clips etc. which would enable users to develop resourceful and more detailed care plans as they go along.

Figure 2.
An example of the notebook.

3.5 Administering Antibiotics
As in a real hospital setting, after handover nurses move on to attend to routine nursing care activities and meeting patients' needs by administering medications and ensuring patients' comfort. In this instance, the two nurses in the simulation proceed to administer antibiotics to the patient in the simulation, Mr. George Parker. While this comprises a very routine event, there are a number of valuable lessons that are being learned by the novice nurse practitioner. These lessons have to do with the appropriate procedures for administering medication, such as reviewing patient notes, policies, procedures and protocols, checking equipment, and also consulting expert practitioners.

Demo 4. A real G2 streaming movie showing the video clip of administration of antibiotics

3.6 Precipitating Event
Following the administration of antibiotics on Mr. George Parker, users are met with a "precipitating event". A precipitating event in this instance is an emergency situation that causes, or has the potential to cause, a chain of events. It requires the nurse to make complex decisions under the pressure of time. Within this learning environment, however, time is not a variable because this is a contrived learning situation in which users have the opportunity to review relevant documentation and seek advice from experts, if necessary, on the best practice before making decisions. As such, this comprises a "safe" learning environment for users where they can make mistakes with impunity. Being able to learn from one's mistakes is an important point that is being made here. This is possible in this learning environment but obviously not possible in real life situations.
Demo 5. A real G2 streaming movie showing the video clip of George Parker experiencing anaphylaxis

3.7 Managing the Situation
In the first instance, the nurse must do everything that is necessary to manage the crisis situation before recommending a care plan. In order to do this, it is necessary to first understand the crisis situation, including its causes. In this scenario Mr. George Parker (patient) is experiencing an anaphylactic reaction to the antibiotics he was administered earlier. To diagnose this situation accurately, the learner needs to assess the patient's condition. In order to arrive at a correct diagnosis, the novice nurse practitioner can access a whole range of information including documentation on hospital procedures/protocols, stories by expert practitioners (experienced nurses) which also comprise advice on appropriate procedures to follow or not to follow under such circumstances.

Demo 6. A real G2 streaming movie showing the video clip of the two nurses attending to George Parker

3.8 Learning Transcation
Following this diagnosis, nurse practitioners must take appropriate action to manage the crisis situation. But before this is possible, they are prompted by the simulation to identify and sequence (from lists) appropriate actions that are necessary for correct diagnosis and management of the anaphylactic reaction. For example, during diagnosis the system asks the learner, "What would you be looking for to confirm that George Parker is at risk of an anaphylactic reaction?" It allows users to choose from a list of past events or patient characteristics the appropriate triggers that would confirm that this patient is, indeed, at risk of an anaphylactic reaction. This learning transaction requires learners to make decisions about prioritising and delivering appropriate care.

Figure 3. An example the drag and drop activity

A number of resources are available to users at this point to enable them to make informed decisions about what are the appropriate actions to take in situations like this. These comprise electronic resources on anaphylaxis including intervention strategies and case studies of anaphylaxis.

Figure 4. An example Internet access site

However, the most important resource that users have access to in this learning environment is the stories of experienced nurse practitioners. Users are able to make informed decisions after having listened to the experiences of expert practitioners. These stories represent the "strategic" (also known as the experiential) knowledge of expert practitioners. This kind of knowledge comes only with experience over many years, and is not normally available in textbooks. Most computer-based (including on-line) learning environments fail to bring good stories to the student. They tend to concentrate too much on "declarative" content (ie., facts, procedures and principles), but they fail to recognise that people learn most effectively from the experiences of expert practitioners. This learning environment relies on using cases and stories, and experiences of expert practitioners to enable novice practitioners to make appropriate and informed decisions. This is where the learning takes place.
Demo 7. A real G2 streaming movie showing the video clip of a powerful story

3.9 Reflecting at Case Conference
When a care plan has been developed, users proceed to a case conference. This is a place where users have the opportunity to reflect upon their own care plans and that of others. They have the opportunity here to engage in collaborative questioning, critiquing, negotiation of meanings, and commenting on alternative approaches of care that are deemed appropriate to the case. This can invoke cognitive conflict in the learner, which has the potential to lead to changing perceptions that result in learning.

Demo 8. A real G2 streaming movie showing the video clip of case conference

3.10 Developing a Care Plan
By now, novice practitioners are in a position to develop a care plan that is based on informed decision making. It will have become clear to users that the process of reaching this stage is more important than having the care plan accepted by their supervisors. This process has been designed to develop in learners clinical decision making skills, and it seeks to achieve that by urging users to learn from the experiences of expert practitioners. Its expressed intent is to expose nurses to the process of clinical decision making and encourage them to make decisions on this basis so that this process becomes almost automatic for them. Ultimately, within this "case-based reasoning" environment, users are able to improve their problem solving skills and ability with making appropriate clinical decisions concerning patient care.

4. Procedure
The first step in the development procedure for this project was to develop and shoot the "precipitating event." The experiencing of anaphylaxis was chosen as the event because it represents a reasonably complex occurrence in a hospital as well as a common scenario in the community, for example, it may occur when children receive immunisations at the clinic, or when someone has been stung by a bug, etc. Except for the patient experiencing anaphylaxis, all other participants in this video shoot were educators and health professionals. The next major task was to capture a large enough repository of the experiences of nurse practitioners in the form of stories. Gathering this repository was no mean task. Interviewing, filming, and editing of these stories took up much time. Indexing of the database of these stories was an ongoing exercise.

The model of learning outlined in Figure 1 guided the development of the learning transaction. This unfolded in several phases. Within the multimedia simulation, users could move easily from activity to activity towards their ultimate goal, which was the successful management of the presenting problem. Some of these activities comprised making selections from a number of decision options, dragging and dropping them in appropriate boxes, deciding to administer a particular treatment or not, deciding to call for help or not, choosing to consult expert video clips for advisement or not, and making decisions. Resources apart from expert's stories such as procedures and other reference manuals had to be identified and collected for the reference of users.

5. Development
The development of this interactive multimedia courseware product adopted a user-oriented approach (Goodyear, 1995) that comprised ongoing testing and formative evaluation of the prototype by experts in multimedia courseware development, content experts and a selected sample of intended users. The multimedia courseware has been developed using Asymetrixís Multimedia Toolbook™, a quasi-object-oriented, event-driven development system for Microsoft Windows™. Toolbook™ combines database functionality, text manipulation, hypertext, drawing capabilities as well as a full-featured programming language called OpenScript™ which allows the developer to program object behaviour. Toolbook™ offered the development team rapid prototyping capabilities and thus allowed quick responses to user-initiated changes during the development process. This prototype is currently undergoing a series of iterations of progressive development. The highly modular nature of object-oriented programming allows the developer to test each object and its behavioural characteristics. This learning system contains both generic content about the diagnosis and management of anaphylaxis as well as specific procedures and protocols that are specific to St. Vincentís Hospital in Toowoomba, Queensland, Australia, which has served as the reference site. Furthermore, in order to achieve the most realistic nursing clinical decision making environment possible, all participants in the video clips used in this multimedia courseware are nursing practitioners who have volunteered their time and effort. Further enhancements of this product will be undertaken after the formal evaluation of this multimedia learning environment. Conversion from CD ROM to a Web compatible environment is planned.

6. Evaluation
Our approach to the monitoring and evaluation of the outcomes of this project is utilisation focussed. As such our focus has been on the use and utility of the instructional innovation for nursing students, their lecturers, graduate nurses, and other stakeholders such as the employing institutions. Evaluation of the courseware prototype is continuing. Formative evaluation of courseware has been carried out with small groups of potential users including a small group (n=3) of subject matter experts who were asked to validate, among other things, the authenticity of anaphylaxis. A semi-structured Expert Group Checklist (see Appendix A) has been used for gathering the comments of the expert group. A semi-structured questionnaire including an Interface Rating Scale (see Appendix B) has been used to collect data from the group of potential users. A larger scale implementation evaluation of this courseware is planned. This will involve observations, focus groups and use of semi-structured questionnaires.

Results of the formative evaluation carried out so far show that users find the learning program easy to use and navigate. The majority did not find the information overwhelming, and felt that the content was pitched at an appropriate level for the target group. With regards to interface design, users felt that the screen design was pleasing, appropriate use of graphics had been made, and that the clarity of information presentation was high. On the whole users surveyed found the program enjoyable. Subjects were asked how interesting they found the material on each one of the sections on the CD. Material on the CD was itemised to include: Handover, attending to patient, listening to stories, making decisions, and preparing the report. The majority found each one of these sections as either interesting or very interesting. Subjects were also asked to rate the usefulness to them of these same attributes. All of them rated these attributes either useful or very useful. In summary, what they liked most about this multimedia-based simulation included simple access to different components, more interesting information, better retention in comparison with reading a journal article or book, realistic presentation, and interactive patient observation.

7. References

Bower, G. H. & Hilgard, E. R. (1981). Theories of Learning. Prentice-Hall, Inc., Englewood Cliffs, N. J.

Brown, A. L. & Palincsar, A. S. (1989). Guided, cooperative learning and individual knowledge acquisition. In L. B. Resnick, ed., Knowing, Learning and Instruction. Lawrence Erlbaum Associates, Hillsdale, New Jersey, p. 393-451.

Chin, C. A. & Brewer, W. F. (1993). The role of anomalous data in knowledge acquisition: A theoretical framework and implications for science instruction. Review of Educational Research, 63, pp. 1-49.

Goodyear, P. (1995). Infrastructure for Courseware Engineering. In R.D. Tennyson & A.E. Barron (Eds), Automating Instructional Design: Computer-Based Development and Delivery Tools, Berlin: Springer-Verlag.

Savery, J. R., & Duffy, T. M. (1995). Problem Based Learning: An Instructional Model and its Constructivist Framework, Educational Technology, September-October, pp.31-37.

Schank, R. C. & Cleary, C., (1995). Engines for Education. Lawrence Erlbaum Associates, Publishers, Hillsdale, New Jersey.

Schank, R. C. (1990). Tell Me A Story. Northwestern University Press, Evanston, Illinois.

Schank, R. C. (1997). Virtual Learning. McGraw-Hill, New York.

8. Acknowledgments
This project has been funded by The Committee for University Teaching and Staff Development, The Federal Department of Education and Youth Affairs, Australia.

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IMEJ multimedia team member assigned to this paper
Ching-Wan Yip